Provider Demographics
NPI:1861596892
Name:WYCHE, SAMUEL PHILLIP JR (DO)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:PHILLIP
Last Name:WYCHE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8200 FLOURTOWN AVE
Mailing Address - Street 2:SUITE 1 B
Mailing Address - City:WYNDMOOR
Mailing Address - State:PA
Mailing Address - Zip Code:19038-7976
Mailing Address - Country:US
Mailing Address - Phone:215-836-7014
Mailing Address - Fax:
Practice Address - Street 1:8200 FLOURTOWN AVE
Practice Address - Street 2:SUITE 1 B
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-7976
Practice Address - Country:US
Practice Address - Phone:215-836-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-005924-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE70780Medicare UPIN
PAWY648592Medicare ID - Type Unspecified